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Conference Abstracts |
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SYMPOSIA ABSTRACTS - THURSDAY 20 JULY SYMPOSIUM 1
Prevention of Psychological Distress among Children and Adolescents Matthew R. Sanders, University of Queensland, Brisbane, Australia A Population Perspective in Behavioural Family Intervention Matthew R. Sanders, University of Queensland, Brisbane, Australia Family conflict and poor parenting are generic risk factors associated with a wide variety of adverse developmental outcomes in children including increasing risk for conduct problems, drug abuse, delinquency and academic underachievement. This paper makes the case for the importance of a population perspective in addressing parenting and family risk factors related to the development of child psychopathology. A comprehensive multilevel model of parenting and family support is presented. Empirical evidence concerning the efficacy and effectiveness of media, primary care within a brief consultation format, and more intensive family intervention programs are discussed. Predictors of differential response to different levels of intervention are highlighted. The evidence reviewed shows significant effects across several trials on both child and parent mental health outcomes (particularly depression and marital conflict). Challenges in working with families where parenting problems are complicated by other forms of adult distress are discussed.
The Mass Media and the Prevention of Child Behaviour Problems: The Evaluation of a Television Series to Promote Positive Outcomes for Parents and their Children. Matthew R. Sanders, Danielle T. Montgomery, & Margaret L. Brechman-Toussaint, School of Psychology, The University of Queensland, Australia This paper examines the impact of a media based intervention strategy “Families” a 13 episode television series on child disruptive behaviour and family adjustment. This media based “infotainment” style intervention comprises the first of a five level early intervention parenting and family support strategy, known as Triple P-Positive Parenting Program. Fifty-six parents of children aged between 2 and 8 years were randomly assigned to either watching the television series or to a waitlist control group. Compared to the control group, parents in the television viewing (TV) condition reported significantly lower levels of disruptive child behaviour and higher levels of perceived parenting competence, immediately following intervention. All post intervention effects were maintained at 6-month follow-up. Prior to intervention approximately 42% of the children in the TV condition were in the clinically elevated range for disruptive child behavioural problems. This had reduced to 14% following intervention and maintained at that level at 6-month follow-up. In addition, parents in the TV condition reported a high level of consumer acceptability. Implications for public health approaches to family mental health will be discussed.
Enhanced Self-directed Behavioural Family Intervention for Families in Rural and Remote Areas Carol Markie-Dadds, Matthew R.Sanders, and Jackie Smith., School of Psychology, The University of Queensland, Australia Although there is a similar incidence of childhood behaviour disorders in rural as in urban areas several barriers prevent families living in rural areas from accessing traditional treatment services. Many towns in rural Australia have no child and adolescent mental health services at all while other towns receive services on a rotational basis by visiting professionals. Interventions that do not require face-to-face contact with a family may be able to effectively address this gap in service. This paper describes an enhanced self-directed behavioural family intervention specifically designed for families living in rural and remote locations. The program aims to enhance parenting skills and competence and thereby prevent serious behavioural disorders of childhood. Parents are taught 17 parenting skills to increase prosocial child behaviours and decrease problem behaviours in home and community settings. Enhanced Self-directed Triple P consists of a written parent training package and weekly telephone consultations for 10 weeks. In the present study, forty-five families with a preschool-aged child were recruited from rural Western Australia. Families were randomly allocated to (i) Enhanced Self-Directed Triple P, (ii) Standard Self-Directed Triple P; or (iii) a wait list control group. Families in the Standard condition received the written parent training materials but no telephone support. No intervention was provided for families assigned to the control group. Results will be discussed in terms of child behaviour, parenting style and competence, parental adjustment and relationship adjustment. As predicted, the Enhanced program was found to be superior to both the Standard program and the control condition. Follow-up data will also be presented.
Problem Solving for Life: Evaluation of a Program to Prevent Depression among Adolescents Susan H. Spence, Jeanie Sheffield & Caroline Donovan, School of Psychology, University of Queensland, Australia Problem Solving for Life is a universal, school-based intervention designed to prevent the onset of depression among adolescents. After a brief training, the 1-term curriculum was implemented by teachers with year 8 students, aged 12-13 years. The program aimed to teach problem solving and coping skills, and an adaptive cognitive-style for approaching life problems. Schools were matched in pairs on dimensions relating to size of school, gender mix, rural/urban, sociodemography of catchment area and public/private status. Schools from each pair were then randomly assigned to either the preventive intervention or a monitoring only condition. Assessments were completed before and after the program and at 6 months, 1- and 2-year follow-ups. After the first assessment, adolescents were categorised as a) being “at risk” if they showed elevated but non-clinical levels of depressive symptoms; b) clinically depressed if they manifested clinical levels of depression, and c) no elevated depressive symptoms. These groups were then tracked separately throughout the program and follow-up periods to determine whether the program had a differential impact upon different levels of risk. Comparison of 700 young people who completed the intervention, with 700 matched controls, indicated that the prevention group showed a significant decline in self-reported symptoms of depression. This effect was not shown by the monitoring only condition. Those participants who completed the Problem Solving for Life program also showed significantly greater improvements in problem solving skills than those in the monitoring condition. The preventive intervention was also associated with a significantly greater decrease in symptoms of depression for the “high-risk” group, compared to those “high risk” adolescents in the monitoring only condition. The long-term results are still in progress.
SYMPOSIUM 2
Managing Panic: Patient Packs, Palmtops and PCs, Do They Improve Delivery? Derek W Johnston, University of St Andrews Abstract With evidence for the effectiveness of CBT in the management of panic disorder now well established, research attention has been increasingly focused on the development and evaluation of treatment formats which aim to improve the efficiency of CBT delivery. Recent results are presented relating to the value of bibliotherapy and palmtop computers as self-help instructional media to supplement varying degrees of therapist contact. Sharp has compared three treatment formats: a standard regime (8 sessions involving a total of 6 hrs therapist contact); a minimum contact condition (6 sessions i.e. a total of 2 hrs therapist contact); a totally self-administered bibliotherapy condition. The study is designed to have direct relevance to psychological treatment delivery in primary care and examines also the validity and utility of global measures of outcome in such settings. To date bibliotherapy has offered the main alternative to conventional CBT delivery, but the opportunity for more flexible access to instructional material and the unobtrusive in vivo monitoring of anxiety have contributed to the development of computer-assisted formats for panic disorder. This is the subject of two collaborative studies by Kenardy et al, in Queensland, Australia and Dow et al, in Fife, Scotland. Both studies are of identical design involving a comparison of (a) standard CBT comprising 12 once weekly contacts with therapist only; a 6 session condensed version, therapist only; and a 6 session version with palmtop computer; no treatment waiting list control condition. The studies also allow a cross cultural comparison of treatment effects and an examination of treatment process variables in relation to outcome (Casey). Therapist Contact in Cognitive Behavioural Therapy for Panic Disorder and Agoraphobia in Primary Care: A Randomised Controlled Trial. Donald M Sharp1, Kevin G Power2, & Vivien Swanson3 1Institute of Rehabilitation, University of Hull, 2Anxiety and Stress Research Centre, University of Stirling, Tayside Area Clinical Psychology Service., 3Anxiety and Stress Research Centre, University of Stirling. Panic disorder with or without agoraphobia is a prevalent clinical disorder, which places heavy demands on treatment resources in primary care. The efficiency of delivery of psychological treatments for this disorder is therefore important. Previous research has been conducted on psychological treatments delivered with reduced therapist contact but methodological problems preclude firm conclusions. These methodological problems will be discussed and a study presented, designed to take account of such previous difficulties. One hundred and four patients suffering from DSM III-R panic disorder with or without agoraphobia were randomly allocated to receive cognitive behaviour therapy with either “standard” therapist contact, “minimum” therapist contact, or as a bibliotherapy. All patients were seen by the same therapist, in the primary care setting, and all received an identical written treatment manual. Treatment response was measured by means of patient and therapist rated scales of anxiety, depression, and agoraphobic avoidance. Data were analysed in terms of both traditional statistical significance and clinical significance of outcome. Treatment outcome was also assessed in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. Comparative outcome data for the three differing levels of therapist contact will be presented, and the implications of the findings for wider clinical practice will be discussed.
Computer-assisted CBT for Panic Disorder: A Randomised Controlled Trial. Justin Kenardy1, Mike Dow2, Derek Johnston3, Michelle Newman4, & C. Barr Taylor5. 1University of Queensland, Australia., 2Fife Healthcare, Scotland., 3St. Andrews University, Scotland.. 4Pennsylvania State University, USA., 5Stanford University, USA. Previous research has indicated that brief computer-assisted CBT (CA-CBT6) for panic disorder may be as effective as longer standard CBT. The computer-assisted CBT employs palmtop computing devices rather than the usual desktop approach to computer-assisted therapy. This approach may provide unique benefits in the delivery of CBT to the panic disordered patient. In this study a brief (6-session) CA-CBT6 was contrasted with a standard 12-session CBT (CBT12), a brief 6-session non-computer-assisted CBT (CBT6) and a waitlist control. In all 98 patients with panic disorder with or without agoraphobia were randomised into one of the four conditions. At post-treatment all patients in active treatments improved significantly on panic-related measures, avoidance measures, depression, and disability compared to the waitlist. On comparison between active treatments CA-CBT6 and CBT12 performed significantly better than the CBT6, and were not different from each other on most outcome measures including endstate functioning. However CA-CBT6 had significantly better outcomes than CBT12 on trait anxiety, depression, and disability. Predictors of outcome include age (older participants did better), gender (men did better) and avoidance (less associated with better outcome). Thus the hybrid computer-assisted one-to-one therapy is an effective method for delivery of CBT for panic disorder. Furthermore this approach is more cost-effective than standard-length treatments.
Controlled Comparative Evaluation of Computer-Assisted CBT for Panic Disorder: Scottish Results Michael G.T. Dow1, Derek W. Johnston2, Justin Kenardy3, Aileen Thomson1, Michelle Newman4 & C. Barr Taylor5 1Fife Healthcare, Scotland, 2St Andrews University, Scotland, 3University of Queensland, Australia, 4Pennsylvania State University, USA, 5Stanford University, USA The present study was designed as a sequel to a preliminary comparative evaluation of the cost-effectiveness of standard cognitive-behavioural treatment (CBT) and a condensed palmtop computer-assisted CBT programme for panic disorder conducted by Newman et al (1997) in Australia and the United States, in which significant effects of both treatments were observed, with no between treatment differences on most measures. The present study, identical in design and methodology to that of Kenardy et al (present symposium), provides a more extensive controlled trial of palmtop computer-assisted CBT delivery for panic disorder with/without agoraphobia within an NHS setting in West and Central Fife, Scotland. The multi-centred nature of the study in addition to offering the potential for a significant enhancement of statistical power, also affords an examination of the generalisability of Kenardy et al’s findings across populations and treatment settings. The Scottish sample comprised 80 patients randomly allocated to (a) standard 12 session treatment (therapist only); (b) a 6 session condensed version of treatment (therapist only); (c) a 6 session computer-assisted condensed version (therapist plus computer); (d) a no treatment waiting list control condition. Not all follow-up data are as yet available, but the results from within and between groups analyses at post-treatment are presented and discussed. Internet-delivered Early Intervention for Anxiety Kelly McCafferty, Justin Kenardy, & Virginia Rosa, University of Queensland, Australia The internet is seen as a medium for the delivery of healthcare that offers benefits beyond usual media such as printed materials and face-to-face contacts. These include improved access, and “intelligent” information presentation, for example the use of hyperlinks. In this study university students at risk of anxiety disorders were randomly allocated to an internet-based cognitive-behavioural program that addressed cognitions and behaviours that were maladaptive, or a delayed-treatment control. In total 78 participants were recruited into the study, risk assessment was based on scores on the Anxiety Sensitivity Index (ASI). Those with clinical disorders were excluded from the study and directed to appropriate care. The six-session program was accessed by participants from home or from the university. It was password protected and it was possible to track usage of the site for individuals. Those in the internet group improved significantly compared to the delayed treatment group on measures of depression, negative and catastrophic thinking. These changes maintained at follow-up. There was no difference found on the ASI between the two conditions. These results suggest that an early intervention program delivered via the internet is feasible, however it is unclear how changes resulting from use of such a program
SYMPOSIUM 3
Metacognition and Psychological Disorder: Theory, Research and Treatment Adrian Wells, University of Manchester Symposium Abstract: Metacognition refers to the psychological processes that enable individuals to reflect on their own thinking. This area has obvious relevance to understanding psychological disorders and treatment processes in cognitive behaviour therapy. However, this area has been largely overlooked by approaches to psychological disorders. This symposium aims to present recent theory and research linking key metacognitive mechanisms to the persistence of a range of disorders and their treatment
Mood-As-Input and Anxious Psychopathology Graham C.L. Davey, University of Sussex and Helen Startup, University of Sussex This paper reviews the way in which negative mood can interact with the inherent stop rules for a task to generate perseverative responding on that task. A mood-as-input model of this kind has a number of implications for anxious psychopathology. In particular, it provides an explanation of how anxious/depressed mood generates uncontrollable catastrophic worrying, and also suggests a mechanism by which negative mood combines with inflated responsibility to generate obsessive checking.
Dimensions of Metacognitive Belief in Patients With Eating Disorders: A Preliminary Clinical Investigation. Alan Cunningham, University of Leicester, Konstantinos Loumidis, University of Leicester and Eric Button, University of Leicester Metacognition has been implicated in emotional disorder by Wells and Matthews, (1994), and more recently a related construct of thought shape fusion (Shafran, Teachman, Kerry & Rachman, 1999) has been linked to eating disorders. However, little is known about the breadth of metacognitions in eating disorders. This study aimed to explore dimensions of metacognitive belief in eating disorders. 20 patients all satisfying DSM-IV criteria for eating disorders (bulimia nervosa, anorexia nervosa, EDNOS) were selected from a specialist service for adults with eating disorders. A semi structured interview was employed eliciting facets of metacognitive belief about food and eating, utilising a modified version of the methodology employed by Wells & Hackmann (1996) and Loumidis & Wells (1997). The elicited beliefs were subjected to a thematic categorisation and were independently rated by two experienced clinical psychologists. Inter-rater reliability was high. The initial analysis yielded 12 dimensions of metacognitive belief. These were as follows: (1) intrusion, (2) self inferences, (3) punishment, (4) functional interference, (5) displacement of other worries, (6) social comparison, (7) monitoring and control of behaviour, (8) monitoring and control of affect, (9) illness, (10) fusion, (11) body information, (12) cognitive neutralisation. The clinical and research implications for cognitive behavioural theory and practice are discussed.
Depressive Rumination: Relationships with Metacognition and Effects of Attention Training Costas Papageorgiou, University of Manchester and North Manchester NHS Trust and Adrian Wells, University of Manchester Depressive rumination and anxious worry are important characteristic features of mood and anxiety disorders. According to Wells and Matthews’ (1994) Self-Regulatory Executive Function (S-REF) model of emotional disorders, these styles of thinking are associated with, and supported by, underlying metacognitions concerning their functions and consequences. Two studies will be reported examining rumination and metacognitions, and the effects of attention training on recurrent major depression. In study 1, metacognitive predictors of depressive rumination and pathological worry were tested in a sample of 200 non-clinical participants. Consistent with predictions, both positive and negative beliefs about thinking were predictive of rumination and pathological worry and these relationships held when the overlap between rumination and worry was controlled. Cognitive self-consciousness also contributed to the regression in predicting rumination. Study 2 examined the effects of attention training (ATT; Wells, 1990) in the treatment of recurrent major depression. ATT aims to reduce self-focus and increase attentional and metacognitive control. ATT was evaluated in a systematic replication series of patients referred for the treatment of depression. Stable baseline periods were obtained prior to the implementation of ATT and follow-up assessments were conducted at 3, 6, and 12 months post-treatment. The results showed that the procedure was effective in eliminating depressive symptoms, reducing rumination and cognitive self-consciousness, and modifying negative metacognitive beliefs. Treatment gains were maintained at follow-up. The conceptual and clinical implications of these findings will be discussed.
A Preliminary Evaluation of a Metacognitive Focused Therapy for PTSD Sundeep Sembi, University of Manchester & N. Manchester NHS Trust and Adrian Wells, University of Manchester In a recent information processing model of emotional disorder, Wells & Matthews (1994), propose that dysfunction is associated with selection of maladaptive coping strategies. In particular, strategies of rumination/worry and internal threat monitoring are components of a maladaptive syndrome contributing to emotional disorder. In this model, re-experiencing phenomena following trauma represent cognitive adjustment processes that serve to facilitate the development of metacognitive plans for dealing with threat. Individuals who develop PTSD engage in coping and appraisal responses that interfere with the on-line processing of intrusions. Thus, normal cognitive self-regulatory processes are inhibited. It follows from this analysis that a metacognitive focused treatment consisting of blocking maladaptive ruminative coping and use of detached mindfulness, in which the individual does not engage with intrusions in a negative iterative way, should facilitate normal processing. This paper reports the effects of a metacognitive focused intervention (Wells, 2000) in the treatment of 6 patients with PTSD following violent assault. Treatment did not involve imaginal exposure or active restructuring of negative thoughts and beliefs. The results show that the treatment was effective in each case as assessed by standardised measures of psychopathology. Treatment effects were maintained at follow-up.
Metacognition and the Persistence of Worry. Christine Purdon, University of Waterloo, and St. Joseph's Hospital, Hamilton, Ontario, Canada. Wells (Wells, 1997; Wells & Matthews, 1994, 1996) proposes that situational appraisal of thoughts and thought processes, or, "metacognition" plays a central role in the development and persistence of generalized anxiety disorder. Specifically, beliefs about the positive and negative functions of worrying are both factors in worry persistence, the first because it results in selection of worry as a coping strategy and the second because it leads to anxiety over worry itself, which in turn ensures that attentional resources remain focused on worry-relevant stimuli. The present study examines participants' appraisal of worrisome thoughts as it predicts natural active resistance to these thoughts, situational appraisal of thought recurrences, anxiety associated with thought occurrences and subsequent mood state. Findings are consistent with Wells' model of GAD, in that situational appraisal of the recurrence of worry-related thoughts was predicted by metacognitive beliefs. Furthermore, stronger positive beliefs about worry predicted less natural active resistance to worry thoughts whereas concern about the consequences of having repeated worry thoughts was associated with greater natural active resistance. Finally, greater anxiety over thought recurrences and more negative subsequent mood state was associated with greater concern that such thought recurrences would lead to problems in mental and physical functioning. Different sets of metacognitive beliefs and appraisals predicted the persistence of obsessional thoughts. Theoretical and clinical implications of these findings are discussed.
SYMPOSIUM 4
Developments in CBT for People with Learning Disabilities: From Deficits to Disorders John L. Taylor, University of Northumbria at Newcastle and Northgate & Prudhoe NHS Trust Abstract It is now generally accepted that people with learning disabilities are more likely to experience psychological problems than the general population. Despite this many commentators have observed that little is known about the emotional lives of people with learning disabilities. There are many reasons for this omission. They include a lack of concern, or regard for the internal worlds of people seen as different; anxiety regarding the imperative to act if we were to better understand the emotional distress experienced by this marginalised group; and “therapeutic disdain” about having to relate to and work closely with such clients (Bender, 1993). In addition to these problems there has been a lack of well developed instruments to help us assess and understand the emotional needs of people with learning disabilities. Further, practitioners who have considered the evidence base for their therapeutic work have been concerned about the efficacy of interventions that could potentially alleviate the psychological distress of clients with learning disabilities. Despite these difficulties there have been attempts to apply cognitive-behavioural therapies to people with learning disabilities. However, as Stenfert Kroese (1998) has pointed out, these approaches have generally addressed apparent deficits in cognitive processing by people with learning disabilities, rather than focussing on cognitive content (thoughts and beliefs) associated with their disorders. The papers in this symposium describe attempts by practitioners to apply cognitive-behavioural therapies to people with learning disabilities with a range of psychological disorders in ways that involve working with the individual to identify and modify the cognitive distortions underlying their particular problems. Process and outcome data is presented to illustrate the value, as well as some of the challenges in applying these cognitive-behavioural approaches. Bender, M. (1993). The unoffered chair: The history of therapeutic disdain towards people with a learning difficulty. Clinical Psychology Forum, 54, 7-12. Stenfert Kroese, B. (1998). Cognitive-behavioural therapy for people with learning disabilities. Behavioural and Cognitive Psychotherapy, 26, 315-322.
Cognitive-Behavioural Therapy for Psychosis and Learning Disability. Gillian Haddock, University of Manchester, UK. The needs of people who have a dual diagnosis of psychosis and learning disability have been shown to be similar to those who have psychosis and do not have a learning disability. However, services to mental health and learning disability are generally delivered by separate services offering different therapeutic inputs. However, there is growing evidence that cognitive-behaviour therapy can be delivered to people with learning disabilities and that it can bring about significant clinical improvements in mental health. However, there is a dearth of literature of describing cognitive-behaviour therapy for people with both psychosis and learning disability. This paper will describe how the progress in research into CBT for psychosis in non-learning disabled clients can be applied within the learning disability field and will discuss the practical application of this by describing a small treatment study currently being carried out by the author and colleagues.
Cognitive-Behavioural Treatment of Anger Problems in Learning Disabled Offenders. John L Taylor and Raymond W. Novaco, University of Northumbria at Newcastle/ Northgate & Prudhoe NHS Trust, UK and University of California, Irvine, USA. Anger has been found to be an important factor in the development and maintenance of many types of offending behaviours. Many people with learning disabilities have difficulty in managing angry feelings, and poor anger control has been shown to be an important determinant of challenging behaviour. Aggressive behaviour also presents significant problems for staff working in learning disability services. For these, and for other reasons there is a pressing need for continued development of anger treatments and for robust evaluations of their effectiveness with this client group. A detained in-patient group of 127 learning disabled men with offending histories were assessed on a range of anger and aggression measures in order to investigate the nature and scope of anger problems in this population. The psychometric properties of several criterion measures of anger and aggression developed by Novaco were investigated and clinically significant levels of anger problems were found in this population. The diagnostic and screening assessments described above identified 47 patients with clinically severe anger problems meeting the inclusion criteria for an anger treatment trial. The active treatment group received an intensive individual cognitive-behavioural intervention based on a modified version of Novaco’s anger treatment protocol. This paper describes the treatment protocol and discusses a number of process issues involved in delivering this intervention to patients in a secure setting. The results of the preliminary analysis of the outcome data for the controlled treatment trial are indicated.
CBT for People with Learning Disabilities in Context: Researching the Role of Carers Chris Hatton, University of Lancaster, UK. Carers, whether informal or formal, play a central role in the lives of many people with learning disabilities, and are crucial to the success of CBT interventions. Research with carers of people with mental health problems generally has illustrated the importance of carers in influencing user outcomes, such as the link between carer high expressed emotion and relapse in psychosis. However, research concerning carers of people with learning disabilities has generally been fragmented, in terms of: 1) populations studied; 2) methodological approaches; 3) theoretical models adopted. This paper will critically review current research concerning carers of people with learning disabilities. An integrated theoretical model will be proposed for carers of people with learning disabilities and mental problems, using existing models within mental health and health psychology research. The implications of such a theoretical model for CBT research and practice will be discussed.
Constraints and Limitations on the Application of CBT for People with Learning Disabilities. Biza Stenfert Kroese, University of Birmingham, UK. Although behaviour therapy is still the predominant therapeutic approach for people with learning disabilities who have psychological problems, the use of CBT is rapidly increasing amongst clinicians. Ample evidence now exists to show that CBT can be an effective intervention. Moreover, it is an approach, which encourages collaboration between clients and therapists and aims to increase self-determination, thus rejecting the traditional authoritarian stance. However, there are constraints and limitations on this treatment approach which include not only individual characteristics (such as limited communication and information processing skills) but also socio-cultural factors. This paper describes and discusses such factors and uses clinical case illustrations.
SYMPOSIUM 5
OCD: More Questions than Answers? Paul Salkovskis, University of Oxford Why Do Obsessional Thoughts Develop and Persist? Implications From New Data Investigating the Appraisal of Obsessional Thoughts and its Relationship to Resistance, Frequency and Mood State Christine Purdon, Department of Psychology, University of Waterloo, Ontario, Canada. Leading cognitive-behavioural models of obsessive-compulsive disorder (OCD)propose that obsessional thoughts develop and persist because they give rise to negative appraisal that enhance the individual's stake in thought control (Rachman, 1997, 1998; Salkovskis, 1985, 1998, 1999). The greater the individual's stake in control, the more vulnerable the individual is to perceiving failures in thought control as meaningful, harmful and/or dangerous. The present study examines the role of general thought appraisal in natural motivation to control thoughts and the role of interpretation of failures in thought control in thought frequency, anxiety and subsequent mood state. Preliminary analyses suggest that general thought appraisals of responsibility and importance of thought control predicted natural active resistance to the thought. Negative interpretation of the meaning of failures in thought control was associated with greater anxiety over thought occurrences, higher thought frequency and more negative mood state later on. Theoretical and clinical implications of these findings are discussed.
When Is Enough Not Enough - Do OCD Patients Operate Elevated Evidence Requirements in Decision-making? Karina Wahl* and Paul Salkovskis. Department of Psychiatry , Oxford University We assume that the termination of compulsive behaviour is based on a strategic decision making process. These decision making processes are believed to vary on the dimension of a) which criteria are taken into consideration and b) how many of these criteria are seen as sufficient to reach a decision. A previous study (Richards, 1995) showed that individuals with OCD reported using ‘internally referenced criteria’ to reach a ‘stop’ decision, as opposed to ‘externally referenced criteria’, which were reported by the normal controls. In this study we are investigating whether these effects are accounted for by people with obsessional problems operating elevated evidence requirements. Specifically, we are looking at the nature of the criteria they use to reach a stop decision, the number of criteria taken into consideration, and if the decision making process is automatic or strategic. A semi-structured interview was used to ask participants about two recent situations: a situation in which they engaged in a compulsive washing/checking episode and a situation in which they performed the same behaviour in a non-compulsive way. We included individuals with obsessional washing problems, checking problems, and normal controls. Preliminary data are presented.
Cognitive Change in OCD: Is it Related to Type of Treatment and is it Necessary for Change? Maureen L Whittal, Dana S. Thoordarson and Peter D McClean, University of British Columbia Hospital, Canada Recent cognitive behavioral conceptualizations of obsessive-compulsive disorder (OCD) have given rise to cognitively focussed treatments that appear to be as efficacious as exposure and response prevention (ERP). Moreover, there have been recent advances in assessment of cognition in OCD. These assessment measures allow for the tracking of cognitive change between sessions that may shed light on mechanisms of change. For example, do cognitions change at a similar rate to symptoms, are they a precursor to, or do they follow symptom change? Similarly, do cognitively based treatments produce greater amounts of cognitive change compared to strict ERP with no cognitive components? The above questions will be addressed as part of an ongoing treatment outcome study at the University of British Columbia Hospital. Using recently developed cognitive assessment measures given weekly during CBT or ERP protocol therapy, we will attempt to address the issue of the relationship between cognitive and behavioral change and if cognitive change is necessary for behavioral change. Additionally we will also compare the extent of cognitive change in subjects who received CBT or ERP delivered in group or individually.
Targeting Danger Expectancies in Treatment-Resistant Compulsive Washing: Is Anything Else Required? Annette Krochmalik, Mairwen K. Jones, Ross G. Menzies* School of Behavioural and Community Health Sciences, The University of Sydney, Five intractable cases of obsessive-compulsive disorder were treated with the Danger Ideation Reduction Therapy (DIRT) program. All five cases: (1) had displayed excessive washing/cleaning behaviours for at least ten years; (2) had failed to respond to a minimum of two separate, twelve-week drug trials with serotonergic agents; (3) failed to respond to at least 15 sessions of exposure and response prevention at the beginning of the present trial, and; (4) satisfied the DSM-IV criteria for OCD with Poor Insight. DIRT was conducted in 14, weekly, individual sessions or until, in the judgement of the treating clinician: (1) clinically significant gains were apparent with minimal symptomatology remaining, and; (2) clients displayed a sound grasp of the cognitive model underpinning DIRT procedures. At post-treatment, substantial reductions in scores on the Padua Inventory, Maudsley Obsessional-Compulsive Inventory, Beck Depression Inventory and two global rating scales were apparent for four of the five subjects. These improvements were maintained at a three-to-six month follow-up assessment. While one subject remained non-responsive at post-treatment and follow-up, the present findings suggest that DIRT may be a viable option for treatment-resistant cases of compulsive washing. The DIRT package will be described in detail, and the theoretical implications of the findings will be discussed.
What We Know and Don't Know in OCD: Setting an Agenda for Research Paul Salkovskis, Department of Psychiatry, Oxford University Abstract Unavailable
SYMPOSIUM 6
Does CBT Have a Role in the Treatment of Anxiety and Depressive Disorders in Children and Adolescents? Roz Shafran, University of Oxford
The Hounslow School Return Programme - CBT in a Group Setting for School Refusing Children and Adolescents Veira Bailey, Department of Child and Adolescent Psychiatry, Maudsley Hospital, University of London School refusal occurs in approximately 5% of clinic referrals and in 1% of all school-age children. There is major conflict and distress in the family; the child frequently becomes disadvantaged educationally and socially, and is at risk of disabling social phobia and agoraphobia in adult life. A treatment programme is described, the School Return Programme, which is a structured rapid return to school programme in which behaviour rewards are used to reinforce success and cognitive strategies are taught within a group setting to help the child or adolescent cope with anxiety. Work is done simultaneously with parents, teaching contingency management skills and challenging maladaptive cognitions, combined with intensive school liaison. Retrospective outcome data will be presented.
Cognitive-Behavioral Treatment of Panic Disorder in Adolescents Tom Ollendick, Virginia Polytechnic Institute & State University, USA In this presentation, two studies will be presented. In the first, the prevalence and nature of panic attacks in adolescents will be examined and the relations between such attacks and measures of social support, stress, anxiety, depression, and fear will be reported. Results indicate that heightened levels of anxiety and fear, as well as stress in the family and lack of family support are related to panic attack status. Panic attacks were reported by 16% of the sample of 649 non-selected adolescents; more girls than boys reported such attacks. In the second study, a multiple baseline design was used to evaluate the treatment of four adolescents with Panic Disorder with Agoraphobia. Cognitive-behavioral treatment based on Barlow’s model of panic was implemented. Panic attacks were eliminated, agoraphobic avoidance was greatly reduced, and self-efficacy for coping with future attacks was enhanced as a function of treatment. In addition, heightened levels of anxiety sensitivity, trait anxiety, and fearfulness were reduced to normative levels. Implications of these studies for the assessment and treatment of panic attacks and panic disorder in adolescents are highlighted.
Cognitive Behaviour Therapies for Post Traumatic Stress Disorders in Children and Adolescents William Yule, Patrick Smith and Sean Perrin, , Department of Psychology, Institute of Psychiatry, University of London Although only relatively recently recognised in children, PTSD is now known to occur in a substantial number following life-threatening accidents, disasters and violence. The condition can be both debilitating and long-lasting. Hence the need for effective interventions. CBT approaches are widely held to be the treatments of choice. This paper reviews current treatments including prolonged therapeutic exposure and cognitive restructuring as part of a CBT package. The need for working with parents is highlighted. The role of EMDR is critically evaluated and some case studies presented. In large scale disasters, there is a need for crisis intervention. Against the background on the current debate on the efficacy of Critical Incident Stress Debriefing for adult survivors, a new group treatment protocol will be presented with some preliminary findings.
Does a Multimedia Psychoeducational Package for Young People with OCD Enhance Standard Treatment? Isobel Heyman and Ian Frampton, Department of Child and Adolescent Psychiatry, Maudsley Hospital, London. Obsessive compulsive disorder (OCD) in young people is estimated to have a population prevalence of the order of 1%, and the impairment experienced can be significant. Adult studies have demonstrated lengthy delays between the onset of symptoms, and entry to treatment. From experience in a national specialist service for young people with OCD, there also seems to be poor recognition of childhood OCD, with children, families and associated professionals often having little knowledge of the illness, its treatments and prognosis. We have developed a range of psychoeducational methods and materials, to help young people ‘take-charge’ of their OCD, to help remove a culture of blame from the family setting, and to improve understanding and awareness amongst other professionals working with children. Methods we are exploring include conferences for children and families, groups for young people, and developments of a multimedia package, ‘OCD-ROM’. Evaluation of these interventions is underway, with consideration of effects on knowledge, self-esteem, locus of control, OCD symptoms and impairment, and engagement into effective treatment programs.
Approaches in CBT for Depressive Disorders in Adolescence Chrissie Verduyn and Julia Rogers, Manchester Childrens Hospital NHS Trust, Manchester Clinical applications of CBT to adolescents with depressive disorders will be reviewed in the light of recent outcome studies. Developmental and contextual considerations often necessitate modifications of techniques of cognitive therapy used with adults. These will be discussed with reference to a current study evaluating the training of social services staff to use cognitive behavioural methods with vulnerable and hard-to-reach depressed young people.
SYMPOSIUM 7
The Use of Structured CBT Self-Help Materials Chris Williams, University of Leeds
The MRC Prevention of Parasuicide trial. Using Self-help Materials in Conjunction with Therapy Kate M Davidson, Consultant Clinical Psychologist/Research Tutor, Greater Glasgow Primary Care NHS Trust/University of Glasgow and Ulrike Schmidt, Maudsley Hospital, London We have now completed recruitment into this multi-centre trial of brief manualised CBT versus treatment as usual (TAU) for individuals who repeatedly self-harm. Although we do not know the final outcome of the trial, we know that this group of patients frequently do not attend follow-up appointments. We have developed a self-help booklet for patients who repeatedly self-harm which could be used on its own or in conjunction with therapy. The patients who have entered the trial will be described and the self-help materials and how these were integrated into therapy will be discussed.
Help Yourself to Mental Health Lorna Cameron (1), Lesley Maunder(1), Katie Bateman(2), Derek Milne(2) (1)Northumberland Mental Health Trust/ (2) Centre for Applied Psychology, Newcastle University A pragmatic, multi-method, small scale study was undertaken to detail the need for and effectiveness of self help materials within primary care. The problem of disseminating self-help materials throughout a large geographical area was then tackled. Self help materials were not readily available in surgery waiting rooms. GPs deemed self help beneficial for at least a third of patients with mental health problems, but distributed materials in only 5% of cases. GP advice was the most favoured and medication the least favoured form of treatment identified by patients, with medication most frequently offered. Patients receiving self-help in addition to treatment as usual from their GP showed significant decreases in anxiety symptoms compared to those receiving only treatment as usual. Men showed the fastest reduction in anxiety symptoms, with women showing a delayed decrease. Symptomatic decrease was maintained at 6 weeks. Depression symptoms did not differ in either group. The study indicated the need for effective patient self-help materials for use in primary care. With ten self-help topics currently developed, the issue of disseminating the materials throughout a diverse county in the north of the country encompassing both conventional methods and modern technology, ensuring availability in both urban and rural settings is discussed.
Self-Help in CBT: Theme, Variation and Counterpoint Paul Salkovskis, University of Oxford.
Abstract Unavailable
Re-establishing Control: The Development and Preliminary Evaluation of a Self-help Booklet for Survivors of Trauma and their Families. Claudia Herbert, Director of The Oxford Development Centre Ltd. and The Oxford Stress and Trauma Centre Traumatic Events can shatter lives. The effects can be so terrifying that people often feel that they have lost total control and fear inwardly that they 'must have gone mad'. This observation and the desire to help people re-establish control led the presenter to develop a self-help booklet, 'Understanding your reactions to trauma - a booklet for survivors of trauma and their families', following a two-year research study with sufferers of PTSD. This booklet was translated into the Japanese language in May 1999 and more recently into the Turkish language by Dr Mehmet Sungur. It has been distributed to 30,000.00 survivors of the 1999 Turkish earthquake and is presently being evaluated. The development of the booklet, some preliminary evaluative research from the earthquake area, as well as its suggested uses will be presented here.
A National Survey of BABCP Accredited Therapist’s Attitudes Towards and Use of Structured Self-help Materials. Helen Keeley, University of Leeds, Chris Williams, University of Glasgow, David Shapiro, University of Leeds, Norman Macaskill, University of Leeds. The use of self-help has become a topical subject of research in view of the current pressure on mental health services to meet increasing demand however, research is lacking into the use of self-help materials in clinical practice in the UK. A national survey of accredited cognitive and behavioural psychotherapists was carried out in order to assess the extent to which self-help materials are used in the treatment of mental health problems, the manner in which they are used, and therapists’ attitudes and experiences regarding the effectiveness of such materials. A questionnaire addressing these areas was sent to 500 therapists, of whom 265 responded. Responses were used to describe prescriptive practices of the therapists and to describe their beliefs regarding the usefulness and effectiveness of self-help. The majority of respondents reported using self-help materials and considered these materials to be useful and effective. However, self-help methods were generally considered to be inferior to therapist intervention on various measures of outcome, and results suggest that self-help is primarily used as an adjunct to individual therapy to increase understanding and sense of control rather than as an alternative form of treatment. Many therapists do not consider the materials they use with clients to have been adequately evaluated, but this does not affect the frequency with which materials are prescribed.
CBT Self Help: A National and International Perspective Stephen Williams, General Practitioner, The Garth Surgery, Guisborough and Cognitive Therapist at The Whitecliffe Centre, East Cleveland Hospital. The extent of mental health problems in primary care is now well recognised. 25% of consultations in General Practice are concerned primarily with mental health, 90% of which will be managed within primary care itself. However, although these statistics are well accepted, it is easy to forget that this workload is often managed with only minimal or non-existent access to effective psychological interventions. Unfortunately, this may lead to an excessive dependence on isolated medical solutions to psychosocial problems and the use of other interventions that are less well proven than a CBT approach. The potential for applying CBT in Primary Care is not only supported by the evidence but is all too obvious in day to day practice. A period of study leave led me on a quest, partly to develop my own therapy skills and also to search for any answers that professionals, working both in the UK and elsewhere, have found to this mismatch between available CBT resources and clinical need. The effective use of self-help materials seems an obvious possible candidate to meet this "resource gap". This presentation will explore the variety of "assumptions and beliefs" regarding self-help I encountered on this journey, together with the extent to which this approach is being utilised.
Primary Mental Health Care – Delivering Self-Treatment as ‘Health Technology’ David Richards, Senior Lecturer, University of Manchester: for the PHASE research team. The PHASE research programme is a multi-professional, NHS funded, randomised controlled trial of assisted self-help delivered by practice nurses in primary care. For the purposes of training nurses, Managing Anxiety and Depression: A Self-Help Guide - published by the Mental Health Foundation - is conceptualised as a ‘health technology’. For practice nurses, learning how to use it is very similar to learning how to use any new piece of medical technology. Like many other health technologies used in primary care, patients are taught to use it themselves and it is, therefore, similar to home based physical medicine aids such as blood sugar testing machines used by diabetics. The nurse’s role, therefore, is to teach patients how to get the best out of the technology, ensure it is used safely and monitor its continued use by patients so that they can use it independently with little reliance on nurses or other health professionals. Training nurses using this model moves us away from traditional mental health training courses which have attempted to replicate some of the skills of experienced therapists by using short courses for non-mental health practitioners. It is argued that the ‘health technology’ approach is a better skills and cultural fit for delivering primary mental health care.
SYMPOSIUM 8
The Schema Concept Lusia Stopa and Anne Waters,
University of Southampton Schemas are hypothesised cognitive structures which play an important role in cognitive models of psychopathology. Schemas are thought to influence information storage and retrieval and to influence cognitive processes such as meaning assignment, expectations, memory and beliefs (Beck, 1996). There has been particular interest in the role of schemas in the development of personality disorders and Young’s (1994) schema-focused cognitive therapy was developed to treat personality disorders and complex cases by directly tackling the client’s early maladaptive schemas which were thought to be responsible for the presenting problems. Young (1988) developed a questionnaire to measure schemas and there have been some preliminary validation studies of the measure (Schmidt, Joiner, Young, & Telch, 1995). However, there has been only minimal empirical investigation of the concept, methods of measuring schemas or of schema-focused cognitive therapy. The symposium brings together five papers which examine the measurement of schemas, the influence of mood on schema accessibility, and the association between dysfunctional schemas and psychopathology.
The Young Schema Questionnaire: A Comparison of the Short and Long Forms with Two Different Clinical Populations Glenn Waller, St George’s Hospital Medical School, London and Lusia Stopa, University of Southampton Young’s (1994) Schema Questionnaire is a potentially valuable clinical and research tool for the investigation of core beliefs. However, at 205 items it is relatively unwieldy. A briefer, 75-item version has recently been produced (Young, 1998) but lacks the psychometric validation that would demonstrate its utility relative to the longer version. This presentation describes two studies which have compared the long and short versions of the Schema Questionnaire to investigate its psychometric properties. The first study which has been accepted for publication in Cognitive Research and Therapy (Waller, Meyer & Ohanian), aimed to determine whether the long and short versions of the Schema Questionnaire have comparable psychometric properties among a clinical group of bulimic women and a comparison group. The study showed that the two forms had similar levels of internal consistency, parallel forms reliability and discriminant validity, and their levels of concurrent validity were broadly comparable. The second study which is being prepared for publication (Stopa, Thorne, Waters & Preston) compares the psychometric properties of the long version with a derived short version of the questionnaire in a heterogeneous sample of clinical psychology outpatients. The results of this study also show that the two versions of the Schema Questionnaire have similar levels of internal consistency, parallel forms reliability and concurrent validity, and indicate that the short from can be used with confidence by the clinician. However, these results require replication using separate versions of the questionnaire and in a range of different diagnostic groups.
The Influence of Mood on Responses to the Young Schema Questionnaire Lusia Stopa, University of Southampton One important question which has not yet been addressed is whether Young’s Schema Questionnaire (Young 1988) can reliably access the client’s dysfunctional schemas irrespective of mood state. There are two possible hypotheses. One, that the Schema Questionnaire measures a stable and reliable construct and can therefore be used by clinicians and researchers with confidence. Two, that the Schemas Questionnaire reflects mood-congruent distortions in cognitive processing and is therefore not a genuine or reliable measure of the hypothesised construct. This study, which is being prepared for publication (Stopa, Waters & Thorne), addresses these two hypotheses using a mood-induction paradigm to investigate whether mood influences the way that participants respond on the Schema Questionnaire. 30 participants form the University of Southampton completed the Schema Questionnaire on three occasions at least a week apart. There were three conditions which were counter-balanced across participants to control for order effects: positive induced mood, neutral mood or depressed induced mood. Positive and depressed mood were induced using a musical mood induction. Three of the fifteen schemas - emotional deprivation, defectiveness and entitlement - showed a mood dependent difference in responding. However, these differences were not all in the same direction. On the emotional deprivation and defectiveness schemas the participants had higher scores when they were in the depressed mood condition but on the entitlement schema participants had higher scores in the happy mood condition. The implications of these results for both the theoretical status of schemas and the use of the Schema Questionnaire as a measurement tool are discussed.
The Association Between Dysfunctional Schemas and Psychopathology Anne Waters, University of Southampton Dysfunctional schemas play an important hypothesised role in the aetiology and maintenance of a number of disorders. However, to date there has been little empirical investigation of the association between schemas and psychopathology. The present study, which is being prepared for publication (Waters, Stopa, Elliott and Waller), used the short version of the Young Schema Questionnaire (Young, 1998) to identify dysfunctional schemas in a general clinical population and investigated the associations between these schemas and a range of psychopathology measures. General levels of psychopathology were measured using the Millon Clinical Multiaxial Inventory. Levels of anxiety were measured with the State-Trait Anxiety Inventory. The study also looked at the relationship between dysfunctional schemas and two specific areas of psychopathology, namely dissociation and somatoform disorders measured by the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire respectively. The study, which is part of a multi-site investigation into dissociation (Wessex Research Group), has provided extensive data which is currently being analysed. Preliminary analysis has yielded a number of significant findings. The specific associations between dysfunctional schemas and psychopathology will be presented at the symposium and their implications for both cognitive theory and clinical practice will be discussed.
Schemas and Dissociation: A Mediating Role for Dissociation Lisa Sheldon, University of Southampton. There has been relatively little research addressing the relationship between dysfunctional schemas, dissociation, and psychopathology. This study, which is being prepared for publication (Sheldon, Waters and Waller), investigated the relationship between the level of dissociation, the severity of dysfunctional schemas and degree of psychopathology. The sample comprised 30 clients attending a clinical psychology adult mental health service. Each participant completed the short version of Young’s Schema Questionnaire (Young, 1998), the Dissociative Experiences Scale, and the Symptom Checklist 90- Revised. Regression analysis demonstrated that dissociation served as mediator between vulnerability to harm beliefs and general psychopathology. As part of this, a correlation analysis also indicated a dimensional relationship between defectiveness/shame, mistrust/abuse, and vulnerability to harm beliefs and dissociation. Although these results require extension to a larger clinical sample, the findings indicate the potential utility of addressing dissociative symptoms alongside potential triggers such as defectiveness/shame, mistrust/abuse, and vulnerability to harm beliefs.
Core Beliefs in Bulimia Nervosa and Depression: The Discriminant Validity of Young's Schema Questionnaire Glenn Waller, St George’s Hospital Medical School, London It has been suggested that depression and bulimia share common patterns of core beliefs, despite their differences in more superficial levels of cognition (negative automatic thoughts; dysfunctional assumptions ). Recent research (Cooper and Hunt, 1998) appears to support this proposal. However, that research has potentially important methodological limitations. The present study, which has been submitted for publication (Waller, Shah, Elliott and Ohanian), addresses those limitation, assessing a broad range of core beliefs among non-clinical women, non-depressed bulimics, depressed bulimics and depressed patients. Young=s Schema Questionnaire (Young, 1994,YSQ) was used as the measure of core beliefs. All of the clinical groups reported less healthy core beliefs than the comparison women, but the depressed patients and the depressed bulimics had more unhealthy core beliefs that the non-depressed bulimics. Multivariate analysis demonstrated differences between all four groups, including the depressed patients and the depressed bulimics. These findings support the discriminant validity of the YSQ, suggesting that bulimia and depression are differentiated by core beliefs as well as by more superficial cognitive representations. These preliminary results suggest that the YSQ may be a clinically useful measure of schema-level representations in these disorders. If the role of core beliefs in depression and bulimia is confirmed in future research, then there may be a need to adapt cognitive-behavioural treatments for these disorders accordingly.
SYMPOSIUM 9
Cognitions and Family Caregiving Geogina Charlesworth, University of East Anglia
The Process of Caring: A Social-Cognitive Approach J Mitchell Noon, Consultant Clinical Psychologist and Head of Health Psychology, Cornwall Healthcare Trust. Carers are individuals who have day-to-day responsibility for looking after a person who is ill or disabled and unable to live independently. Most often the carer will be a relative or the partner of the person cared for. It is increasingly recognised that carers are central to the health and well-being of those they care for. Accordingly, healthcare and social services professionals are now encouraged to take into account the needs of carers in addition to the needs of the identified patient or client. Most statutory organisations have a policy on carers and guidelines on meeting their needs. Nevertheless, the quality of help given to carers by professionals is variable. The aim of this paper is to provide a social-cognitive model of the experience of caring which takes into account the process by which an 'ordinary individual' becomes transformed into a carer. The model comprises three elements. The first is the notion of the Self with the associated concept of 'self-worth'; the second is Meaning and the process by which events trigger particular emotions; and the third is Access to Resources, which links internal cognitive processes to the wider social and material context. It is suggested that changes in relationships are fundamental to personal cognitive changes and that the model can be used to inform professional helpers about the ways in which carers succeed or find difficulty in coping with the task of caring (Noon, 1999). Noon, J.M. (1999) Counselling and Helping Carers. BPS Books.
Working With Relatives of People with Bipolar Disorder Anne Palmer & Steve Bazirre, Norfolk Mental Health Care NHS Trust Bipolar Disorder is a severe, relapsing and remitting condition, which is characterised by immense variation between sufferer and within individual episodes. Families have to deal with the day-to-day reality of this disorder. The severity of the illness is linked both to environmental stress and dysfunctional family communication patterns. There is an urgent need to understand common troubling issues for the families such as personality/illness distinctions and to offer help so that families are better able to cope and thus maintain the patient's emotional stability. This paper will compare and contrast bipolar disorder to Schizophrenia in terms of affective style and expressed emotion, and describe a group approach to working with relatives.
The Impact of Care in Psychosis Elizabeth Kuipers, Professor of Clinical Psychology, Institute of Psychiatry Research in this area routinely finds that these carers have high levels of distress, are more likely to be depressed than the general population, and find difficult behaviour and social withdrawal problematic. More recent research shows that carers with high levels of Expressed Emotion (EE) are also more likely to have high levels of burden and that appraisal for these difficulties rather that the problems per se may be crucial. Carers with high EE relationships and high levels of burden are also more likely to use avoidant coping (e.g. denial). Similar results have also been found in a first episode study. A recent study of 77 carers where we were able to look at a model of coping, distress and caregiving will be presented. Carers are typically mothers, may be elderly, 50% are in employment, 20% have previous experience looking after another relative with a mental health problem. Women may be increasingly unavailable for these extended caring roles, and careful consideration needs to be given as to how to offer such carers both choice and optimum support
Psychological Effects of Chronic Illness Georgina Charlesworth, Maria Koutantji, Kiki Mastroyannopoulou, University of East Anglia There are many similarities between the psychological impact of chronic physical and mental health difficulties upon the individual and upon their friends and relatives. In spite of these similarities, it could be said that two contrasting approaches have developed in appraisal research in the physical and mental health fields. Predominant research in the physical health field aims to characterise and quantify the impact of the illness upon the person and the family, whereas a large body of mental illness research describes and measures the effect of the family upon the person with the illness. In this presentation we aim to compare and contrast psychological research in physical and mental health in terms of: the impact of illness appraisals on the psychological adjustment of patients and carers; the relationship between patients and carers perceptions of illness; and the relationship between well-being and perceptions of mutual, reciprocal and social support. We will also consider the implications of the research for clinical practice.
SYMPOSIUM 10
Recurrent Major Depression: Cognitive Processes and Treatment Outcome Costas Papageorgiou, University of Manchester and North Manchester NHS Trust
Depressive relapse or recurrence following cognitive behaviour therapy continues to be a significant problem. An understanding of the psychological factors which contribute to relapse or recurrence may inform the development of more effective interventions. A number of candidate cognitive mechanisms have been explored in this context. This symposium will present new empirical data on cognitive processes associated with vulnerability to depression, and predictors of treatment outcome.
The Role of Cognitive Therapy in the Treatment of Chronic Depressive Disorders Jan Scott, University of Glasgow About 30% of people with depressive disorders who are in contact with mental health services experience a chronic episode. These disorders appear to be refractory to standard anti-depressant medication regimes and show a low placebo response rate (about 10%). It has been argued that the low response to anti-depressant medication is predictable given the fact that many of the classic symptoms of severe depression are absent in chronic depressive disorders. Given the predominance of psychological and affective symptoms, it has been argued that cognitive therapy or other brief effective psychotherapies may be more applicable to this client population. This paper reviews outcome research from three recent studies of the use of cognitive therapy in the treatment of chronic depression either alone or in combination with medication. Taken together, these data highlight the importance of cognitive therapy in improving recovery rates as well as reducing relapse and recurrence rates. The main body of the presentation will focus on the recent MRC study of cognitive therapy (Paykel, Scott, Teasdale et al). This work also demonstrated that cognitive therapy may have a specific effect on psychological symptoms such as hopelessness and guilt, as well as social adjustment. Predictors of response to cognitive therapy will also be reviewed.
Assessing Vulnerability to Depressive Rumination: Development and Validation of the Positive Beliefs about Rumination Scale Costas Papageorgiou, University of Manchester and North Manchester NHS Trust, and Adrian Wells, University of Manchester Repetitive negative thinking, in the form of rumination, is a salient cognitive feature of depression. Rumination is associated with a number of negative consequences including the maintenance and exacerbation of depressed mood (Nolen-Hoeksema, 1991), recurrence of episodes of major depression (Just & Alloy, 1997), and delaying depressed individuals’ response to cognitive therapy (Siegle, Sagratti, & Crawford, 1999). Despite these consequences, little is known about the factors that may be linked to a predisposition to ruminate. In an information processing model, Wells and Matthews (1994) hypothesised that vulnerable individuals’ knowledge base may be responsible for the selection and activation of persistent negative thinking, such as rumination, as a coping strategy. They proposed that rumination is guided by metacognitive beliefs concerning the functions and the consequences of this style of thinking. In the first test of this hypothesis, Papageorgiou and wells (2000) found that patients with recurrent major depression held specific positive and negative metacognitive beliefs about rumination. The present series of studies aimed to develop and validate a measure of positive beliefs about rumination, the positive beliefs about rumination scale (PBRS). Factor analyses of the scale demonstrated a replicable single factor solution. The PBRS was found to possess high internal consistency and good test-retest reliability. The scale significantly correlated with measures of rumination, metacognition, and state and trait depression. Finally, the PBRS significantly discriminated between patients with recurrent major depression, panic disorder with agoraphobia, social phobia, and normal controls. Implications of these findings for cognitive models of depression will be discussed.
Perceived and Actual Utility of Rumination in Recurrent Depression Ed Watkins and Simona Baracaia, Institute of Psychiatry, Kings College London Rumination involves focusing and evaluating the self, dwelling on current and past problems, and concentrating on one's feelings and symptoms. Longitudinal studies have demonstrated that rumination is related to the onset and maintenance of depression in both clinical and non-clinical groups (e.g. Kuehner and Weber, 1999). Experimental studies have demonstrated that ruminative self-focus increases depressed mood and increases depressive cognitions (Nolen-Hoeksema, 1996). Theoretical models stress the importance of rumination (Teasdale & Barnard, 1993; Pyszczynski and Greenberg, 1987) in the onset and recurrence of depression. Recent research has found that people with recurrent depression hold beliefs that rumination is useful for making sense of the world, gaining insight and solving problems, i.e. hold positive metacognitive beliefs about rumination (Papageorgiou & Wells, 2000; Watkins & Baracaia, in press). Although previous studies have suggested that in fact rumination is unhelpful and reduces problem solving effectiveness (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky, Tucker, Caldwell & Berg, 1999), these studies confounded increases in negative mood with poor problem solving and only used an undergraduate population. Therefore, in a subsequent experiment, we tested within a clinical population, the accuracy of the perception that rumination is helpful for problem-solving, by comparing never-depressed, recovered-depressed and currently-depressed subjects on an interpersonal problem solving task under the conditions of no prompts, rumination prompts derived from patients or solution-focused prompts. Preliminary findings are reported.
Meta-This, -That and –The Third Thing: Concepts, Measures and Mediation of the Effects of Cognitive Therapy for Depression Richard Moore, Addenbrooke’s Hospital NHS Trust, Cambridge Evidence for cognitive mediation of the effects of cognitive therapy from studies using traditional measures of cognitive content is sparse. In view of this, there has been increasing interest in alternative concepts, including meta-cognition, meta-cognitive insight and meta-awareness. This paper will discuss the differences between these concepts and describe a recently developed measure of meta-awareness. Data from an outcome study of cognitive therapy for residual depression will be presented, including specific effects of different treatments on meta-awareness and prediction of outcome. Implications for further development of treatments for depression will be discussed. |